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Pilot Error

Never turn the plane to a dead engine

By Perseus Echeminada

November 4, 2012

MANILA, Philippines - A combination of pilot error
and a defective engine caused the crash of a Piper Seneca aircraft
carrying Interior and Local Government Secretary Jesse Robredo off
Masbate last Aug.18, investigators said.

The plane was en route to Naga City from the Mactan International Airport in Cebu when it went down off Masbate.

A 14-page draft report of a five-man investigating body created by
former Transportation and Communications Secretary Manuel Roxas II said
the pilot lacked proficiency in handling aircraft in abnormal
situations.

The report said that five minutes after take-off, the pilot sought
permission from air traffic control to climb to 6,500 feet but was
instructed to remain at 2,500 feet until 20 miles out.

Four minutes later the pilot reported the aircraft was at 2,300 feet.
That was the last recorded communication of the plane with the Mactan
air traffic control.

Data gathered by the Manila Area Control Center (MACC) showed that
the Piper Seneca aircraft or flight X4431 was at 4,000 feet heading 353
degrees at 4:07 pm. After eight seconds it was still at the same
altitude, moving 340 degrees.

The aircraft disappeared from the radar screen for a few seconds and reappeared at an altitude of 3,900 feet at 010 degrees.

“Twenty-four seconds later the aircraft was still at 3,900 feet
altitude with a speed of 80 knots. This time the aircraft was 33.7
kilometers from Masbate and 91.1 km from Mactan. Seconds later the
aircraft was monitored at 3,900 feet with speed of 70 knots and heading
345 degrees. This was the last data picked up by MACC before the
aircraft disappeared from the radar display,” the report said.

At 4:25 p.m., the aircraft was reported to have crashed in the waters some 1.1 km from the Masbate airport runway 21.

Survivor’s account

Based on Abrasado’s account, the pilot informed them of engine trouble 23 minutes after takeoff at 3:07 pm.

“Baka hindi umabot ang propeller natin sa Naga. Magbalik tayo Cebu
(Our propellers might not be able to make it to Naga. Let’s go back to
Cebu),” the pilot was quoted as telling his passengers.

But Abrasado said the plane appeared to be flying normally even on
one engine. He texted a staff of Robredo requesting for airline booking
for the secretary and himself for the next available flight to Manila.

“Later he (Abrasado ) sensed that the plane was changing direction
and at the same time noticed an orange indicator on the instrument
panel, initially blinking slowly, and later increasingly faster.
Suddenly, he heard a noise and saw the right hand propeller stop, at the
same time the orange indicator steadily lit,” the report said.

When Abrasado asked if they were returning to Cebu he was told by
Bahinting that they were proceeding to Masbate. The captain reportedly
told them of his three failed attempts to restart the engine.

“Suddenly, he (Abrasado) saw the plane slowly veering to the left for
final approach to the runway but it seemed to him that the pilot
miscalculated the runway and maneuvered the plane too late and they went
past the runway,” the report said.

“Then Abrasado looked at the pilot and saw the latter turn his head
to the right and glance to the rear over his right shoulder, and
remembers seeing his face turn red and eyes wide open (bulging). The
airplane turned right and ditched upward, followed by a swift vertical
nosedive,” the report said.

Civil Aviation Authority of the Philippines investigator Cesar Lucero
told The STAR that turning the plane to the right when the right engine
was already dead was a fatal error of the pilot.

“The cardinal rule among pilots is never turn the plane to a dead engine,” he said.

No pre-flight briefing

Also according to the report, no pre-flight briefing occurred at the Mactan International Airport.

The report also said the student pilot, who was not yet qualified to fly a Piper Seneca, was occupying the pilot’s seat.

Considering that the flight was for a VIP, the student pilot’s Indian
flight instructor should have been on the flight and not his student.

The report also questioned the decision of the pilot to continue the flight 23 minutes after he sensed “propeller problem.”

“If the flight returned to Mactan, it would have landed safely with
still two engines, as the loss of the right engine was after 38 minutes
of flight after the initial propeller problem was noted,” the report
stated.

The loss of the right engine was reported 33.7 km from Masbate
airport and it took 17 minutes flying on a single left engine before the
aircraft crashed 800 meters from the runway.

The report said witnesses testified that the landing gears of the aircraft were deployed.

“The last and fatal decision made was making a right controlled turn
toward the dead engine, the aircraft manual says that if turn is made
towards a dead engine the aircraft will pitch up about 15 degrees
followed by a stall towards the dead engine,” the report said.

“Altitude is the insurance against stalls or spins. Without it recovery is impossible,” it said.

The other findings include: left engine idler shaft was loose, stud
screwed to the crank case broken and the slotted nut missing; lock plate
damaged; left magneto had evidence of burn; all piston rings stuck up;
all piston heads and spark plugs had carbon deposits.

4 comments:

“The cardinal rule among pilots is never turn the plane to a dead engine,” he said.

Try reading any piston-powered twin engine manual, any make, model, type, class.. you will NOT find it written anywhere on there to make any turns into the dead engine.

It will say there that it is RECOMMENDED to turn the plane into the live engine. It says that you can, BUT with skillful coordination and effort.

Being 2,000 feet higher than what he was cleared for is probably what saved Police Senior Inspector Jun Abrasado. It gave the whole flight extra time to clear the area and extend his possibility of survival.

Altitude is not an insurance against stalls and spins. It helps but it does not guarantee a recovery. I've been in flights where students lose more than 5,000 feet before the instructor recovers for him. On the flipside, I've been in flights where a stall was recovered with a loss of 400 feet; and a spin recovered after 1,000 feet.

Proficiency in stalls and spins IS the insurance against stalls and spins. YOU CANNOT LEAVE YOUR LIFE IN THE HANDS OF NATURE'S INCONSISTENCY.

Another aircraft manual says that if you pitch an aircraft up by 16 degrees, it will stall. All aircraft will stall at a specific angle regardless of type, or situation depending on its current speed. I can be flying at the speed of sound at 15 degrees with one engine dead and I'd still be climbing. THE PITCH IS DEPENDENT ON THE SPEED & V.V.

“The last and fatal decision made was making a right controlled turn toward the dead engine,..." HOW CAN YOU CRASH A PLANE BY MAKING A CONTROLLED TURN???

Lets backtrack... a pilot dies because one of his engines quit. Did anyone ask why it quit? Oh yeah, someone did. They found a shaft was loose, a screw was broken, a nut missing, overheated magneto, stuck pistons, and dirty spark plugs.. AND YET ITS CALLED PILOT ERROR.

The Piper Seneca plane that crashed in Masbate Bay, killing Interior Secretary Jesse Robredo and two others last Aug. 18, did not undergo an actual flight test when the aircraft owner, Aviatours Fly’n Inc., applied for the renewal of the plane’s airworthiness certificate last January.

This is according to the 14-page draft aircraft accident investigation report, which also revealed that the ill-fated plane was not among the light planes that the Civil Aviation Authority of the Philippines (CAAP) allowed Aviatour to maintain, repair and operate.

The Piper PA -34-200, which was manufactured in 1972, was issued a certificate of airworthiness by the US Federal Aviation Administration on Sept. 24, 2007. It was registered by CAAP on Oct. 4, 2007.

The report said the maintenance history of the Piper Seneca revealed that the aircraft was grounded from Oct. 28 up to last Feb. 2.

On Oct. 28, 2011, there was a pilot remark in the aircraft log book that states there is a need to install a new propeller. The propeller was sent to AEROMANIA, the CAAP approved repair station, for overhaul, on Nov. 5, 2011.

On Nov. 19, 2011, the Aviatour logbook stated that the defective propeller on the right engine was fitted as indicated in their application for renewal of airworthiness certificates.

On the same date a test flight permit indicated that a one-hour test flight was flown by Capt. Federico Omolon III found the aircraft satisfactory for airworthiness renewal.

“However, there was no record/entry on the aircraft log book for this flight. Check on the MCIA flight operation log book revealed that no flight plan for RPC-4431 was filed that day,” the report said.

The airworthiness certificate for the ill-fated plane was issued last Feb. 2, with Jan. 6, 2013 as the expiration date.

The report noted that the inspection of the right engine retrieved from the crash showed there was no problem with the propeller but the right engine shaft was loose.

”The stude that was screwed to the crankcase was missing... Lock plate was damaged,” it added.

Civil aviation authorities will now have to trace the planes cleared by the same inspector who declared the airworthiness of the Piper Seneca plane that crashed in Masbate on Aug. 18, killing Interior Secretary Jesse Robredo, according to officials.

Crash investigators discovered connivance between the Seneca plane pilot, Capt. Jessup Bahinting, and inspector Fernando Abalos for the issuance of a certificate of airworthiness to the ill-fated plane without actual tests in early 2012.

The Civil Aviation Authority of the Philippines on Wednesday placed Abalos on a 90-day preventive suspension pending investigation of his culpability in the crash.

“The Caap will have to go over everything that he handled. All that he inspected, all that he approved will have to be checked if they’re in order,’’ Secretary Edwin Lacierda, presidential spokesperson, said in a briefing.

Caap Director General William Hotchkiss would first focus on the air operators and flying schools that had been cleared by Abalos, Transportation and Communication Secretary Joseph E.A. Abaya said.

“He will now define the universe: the planes, schools and entities that passed through the hands of Abalos. He will focus on them because these are highly suspect. There’s evidence that there was fabrication and cutting of corners. So you start on that,” Abaya said by phone. “The audit of the rest will follow.”

The investigators found out that Abalos approved a test flight permit for the Seneca Piper plane’s renewal of airworthiness certificate on Jan. 7 this year, but there was no record of such test flight.

On Jan. 17, Abalos also endorsed the application for renewal of airworthiness certificate, and an entry in the database showed the relevant documents had been reviewed by him. Then on Feb. 2, the certificate was issued to AviaTour, which was owned by Bahinting.

The investigators said the test flight results were falsified, and concluded that Bahinting connived with Abalos to “expedite’’ the processing and approval of the certificate of airworthiness.

After reading the investigators’ report, President Benigno Aquino III blamed Bahinting for the crash. Investigators cited Bahinting’s inexperience to handle emergency situation, and his failure to turn back to Cebu after one of the two engines malfunctioned 23 minutes into the flight.

The investigators also blamed a faulty engine and the flawed management of AviaTour.

The plane took off from the Cebu airport in the afternoon of Aug. 18, and crashed into the Masbate Sea en route to Naga City, killing Robredo, Bahinting and his co-pilot Kshitiz Chand. Robredo’s aide, Senior Inspector June Abrazado, survived.

In a statement posted on government website, Caap Deputy Director General John Cu Unjieng Andrews said Abalos’ acts could constitute gross dishonesty and grave misconduct that might warrant removal from government service.

Andrews said Abalos would be accorded due process in the investigation to be conducted by a board created by Hotchkiss.

As the results of the investigation became public Tuesday, the President ordered an audit of the permits and licenses issued by the Caap.

Caap said permits of some 39 flying schools, 21 air taxi operators, and 24 maintenance organizations would be audited.

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